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May 2008 Journal of Dental Education 571

Dental Students Beliefs About Culture inPatient Care: Self-Reported Knowledge and

ImportanceJulie A. Wagner, Ph.D.; Deborah Redford-Badwal, D.D.S., Ph.D.Abstract: In order to decrease the well-documented disparities in oral health and oral health care, the next generation o dentists

must be prepared to serve a diverse patient population. This article describes dental students sel-reported knowledge o culture

and importance o using culturally sensitive dental practices. Three consecutive graduating classes (n=111) were surveyed anony-

mously in their sophomore years. Students indicated their sel-rated knowledge o oral health and oral health care or their own

culture and the cultures o patients they are likely to see in dental practice. Students also rated their perceived importance o cul-

turally sensitive dental practice. Overall, students reported low knowledge o the cultures o the patients they will see in practice.

Few students could identiy any cultural group that they knew well. However, students as a group indicated that using culturally

sensitive practices in dentistry is important. Students who could identiy at least one cultural group they knew well perceived

cultural sensitivity in dental practice as more important than students who could not. These results suggest that students need

cross-cultural training and believe that such training is important. The results also suggest that a specic curriculum that increases

knowledge o other cultures may have the potential to ultimately increase the use o culturally sensitive practices.

Dr. Wagner is Assistant Proessor, Division o Behavioral Sciences and Community Health, Department o Oral Health and

Diagnostic Sciences; and Dr. Redord-Badwal is Associate Proessor, Division o Pediatric Dentistry, Department o Cranioacial

Sciencesboth at the University o Connecticut School o Dental Medicine. Direct correspondence and requests or reprints to

Dr. Julie Wagner, Division o Behavioral Sciences and Community Health, MC3910, University o Connecticut Health Center,

263 Farmington Ave., Farmington, CT 06410; 860-679-4508 phone; 860-679-1342 ax; [email protected].

This project was supported through a grant rom the Robert Wood Johnson Foundation.

Key words: dentistry, students, diversity, multicultural

Submitted for publication 9/5/07; accepted 2/12/08

Changing demographics in the United States

demand that new dentists be prepared to treat

a diverse patient population. Immigration

patterns point to signicant increases in racially,

ethnically, culturally, and linguistically diverse popu-

lations. According to the U.S. Census Bureau, one

in every ten persons in the United States is oreign-

born.1 Currently, the U.S. oreign-born population

comprises a larger segment than at any time in the

past ve decades, and this trend is expected to con-

tinue. In 2000, 18 percent o the total population aged

ve and over, or 47 million people, reported they

spoke a language other than English at home.2

From 1995 to 2050, the United States will gain

80 million new immigrants and their descendants,

or 25 percent o the total population. Projections or

2050 point to 820,000 net immigrants a year, com-

prised o 350,000 Hispanics, 226,000 non-Hispanic

Asians, 186,000 non-Hispanic whites, and 57,000

non-Hispanic blacks. Thus, Hispanics and Asians will

contribute the most to the infux o immigrants.3

The U.S. surgeon generals 2000 report on oral

health in America4 reveals proound and consequen-

tial oral health disparities along racial and ethnic lines

within the population. Although common dental dis-

eases are preventable, social, economic, and cultural

actors aect how health services are delivered and

used and how people care or themselves. Reduc-

ing disparities requires wide-ranging approaches,

including training a workorce that is responsive to

the cultural needs o patients.

According to the National Center or Cultural

Competence,5 critical actors in the provision o

culturally competent health care services include

understanding o the ollowing: the belies, values,

traditions, and practices o a culture; culturally de-

ned health-related needs o individuals, amilies,

and communities; culturally based belie systems o

the etiology o illness and disease and those related

to health and healing; and attitudes toward seeking

help rom health care providers.

Dental schools must strive to prepare their

students in these areas. Ideally, the next generation o

dentists would be knowledgeable about the cultures

they will treat and skilled in using culturally sensi-

tive health care delivery practices. However, little


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572 Journal of Dental Education Volume 72, Number 5

is known about students own belies about treating

diverse patients. For example, educators know little

about students perceptions o their own strengths

and weaknesses, whether students perceive culture

as important to the practice o dentistry, and whether

there are modiable predictors o the perceived im-

portance o culturally sensitive practices. The aims

o this study are to 1) describe students sel-rated

knowledge o their own culture; 2) describe students

sel-rated knowledge about the cultures they are likely

to encounter in dental practice; 3) describe students

belies about the importance o culturally sensitive

practices in dental care; and 4) identiy modiable

characteristics o the perceived importance o cultur-

ally sensitive practices.

MethodsThe multicultural curriculum at the Universityo Connecticut School o Dental Medicine (UConn

SDM) is delivered in a stepwise ashion. The cur-

riculum progresses through didactic lectures, small

group seminars with student presentations, patient-

instructor rotations, a public health policy course, and

community health center rotations. At the beginning

o their sophomore year, students are introduced to

the multicultural curriculum with a lecture in their

pediatric dentistry course. During that class, students

complete an anonymous survey regarding their sel-

rated knowledge o culture in dentistry and theirperceived importance o using culturally sensitive

practices in dental care. The UConn Institutional

Review Board approved this study.

This investigation employed a cross-sectional

observational design. Students completed portions

o the 2004 version o the values and belie sys-

tems measure o the Cultural Competence Health

Practitioner Assessment (CCHPA).6 The CCHPA

was developed by the National Center or Cultural

Competence at the request o the Bureau o Primary

Health Care, Health Resources and Services Ad-

ministration, U.S. Department o Health and Human

Services. Results o the preliminary analysis o the

psychometric properties o the CCHPA are very

strong, and actor analysis conrms meaningul

actor structure. The CCHPA shows strong internal

consistency reliabilities (Cronbach alphas .95.97 or

each measure). There is also preliminary evidence

o concurrent validity: that is, the CCHPA predicts

cultural and linguistic competence.7 Students were

not administered the entire CCHPA because it is

very long and much o it assesses actual health care

delivery practices that are not applicable to preclini-

cal students.

The values and belie systems measure o the

CCHPA concerns knowledge o the health-related

values and belie systems o diverse cultural groups

and their impact on health care access and utiliza-

tion. The measure has three subscales, each o which

is comprised o several items. The rst subscale

encompasses seven items, or which respondents

rate their knowledge o their own culture. The item

stem states, I know and can articulate the ollowing

belie systems ormy own culture. Respondents rate

their knowledge o denitions o health, illness, well-

being, care-seeking behaviors, traditional health prac-

tices, spirituality, and amily/community dynamics.

Response options are 1=not at all, 2=barely, 3=airly

well, and 4=very well. Scores on these items are

summed and divided by 7 to yield a mean subscale

score or knowledge o own culture.

The second subscale encompasses seven

items, or which respondents rate their knowledge

o cultures they are likely to treat in practice. The

item stem states, I know and can articulate the

ollowing belie systems o the cultures I am likely

to encounter while practicing dentistry in Connecti-

cut. Respondents rate their knowledge in terms o

denitions o health, illness, well-being, care-seeking

behaviors, traditional health practices, spirituality,

and amily/community dynamics. Response optionsare 1=not at all, 2=barely, 3=airly well, and 4=very

well. Scores on these items are summed and divided

by 7 to yield a mean subscale score or knowledge

o other cultures. Respondents are also asked to

write in answers to the ollowing question: I know

well the oral health status o the ollowing groups.

Qualitative responses are noted, and the number o

groups indicated is summed.

The third subscale encompasses ve items,

or which respondents rate the importance they

place on attending to patient culture in health care

practice. The item stem states, I believe that whenI start practicing dentistry, it will be important or

me to. . . . Items include using a history interview

that elicits cultural practices, developing aliations

with community organizations, using trained medical

interpreters, keeping abreast o research regarding

the cultural groups served, and participating in cul-

tural competence proessional activities. Response

options are 1=not at all important, 2=not important,

3=important, and 4=very important. Scores on these

items are summed and divided by 5 to yield a mean


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May 2008 Journal of Dental Education 573

subscale score o perceived importance o culturally

sensitive dental practices.

Minor modications were made to the values

and belies systems measure. First, we modied the

language o several items to emphasize dentistry.

For example, we replaced the phrase health status

with the phrase oral health status. Second, we made

the survey relevant to our geographic location. For

example, we replaced the phrase in my service area

with in Connecticut.

One hundred and eleven students rom three

graduating classes participated. Pediatric dentistry is

a required course during the sophomore year at the

University o Connecticut School o Dental Medicine.

All students who attended the required class during

which surveys were administered were investigated.

Thirty-ve students rom one graduating class par-

ticipated. This graduating class averaged twenty-ve

years o age; 54 percent were emale; 61 percent were

rom New England; and the class had the ollow-

ing racial/ethnic composition: 66 percent white, 12

percent Arican American, 10 percent Asian/Pacic

Islander, 7 percent Hispanic, and 5 percent other or did

not report. Thirty-eight students rom the subsequent

graduating class completed the survey. This graduat-

ing class averaged twenty-six years o age; 37 percent

were emale; 47 percent were rom New England; and

the class had the ollowing racial/ethnic composition:

63 percent white, 13 percent Arican American, 3 per-

cent Asian/Pacic Islander, 13 percent Hispanic, and8 percent other or did not report. Forty students rom

a third graduating class participated. This graduating

class averaged twenty-our years o age; 49 percent

were emale; 88 percent were rom New England;

and the class had the ollowing racial/ethnic composi-

tion: 87 percent white, 3 percent Arican American,

8 percent Asian/Pacic Islander, and 3 percent other

or did not report.

Analysis o assumptions revealed normal dis-

tribution o CCHPA subscale scores. To describe stu-

dents belies, descriptive statistics were calculated.

To compare students knowledge o their own andothers cultures, a dependent t-test was perormed.

To investigate the relationship between knowledge

o culture and importance o cultural sensitivity,

an ANOVA was perormed with knowledge as the

independent variable and importance as the depen-

dent variable. Classes were combined or analyses;

to protect against any potential dierences by class,

graduating class was entered as a covariate in ap-

propriate analyses. Data were analyzed using SPSS,

with alpha set a priori at .05.

ResultsA dependent t-test was perormed, comparing

within-person dierences on the knowledge o

own culture subscale and the knowledge o oth-

ers cultures subscale. Results showed that studentsreported higher knowledge o their own culture than

the cultures they believe they are likely to treat while

practicing dentistry in Connecticut, t(111)=11.68,

*p


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knowing at least one cultural group well is related to

higher perceived importance o using culturally sen-

sitive dental practices. These ndings are consistent

with literature that suggests that gaining knowledge

o specic cultural groups is an important part o im-

proving provision o culturally sensitive health care.

For example, Lister8 posits that cultural knowledge

(amiliarity with the broad dierences, similarities,

and inequalities in experience, belies, values, and

practices among various groupings within society) is

an important element o cultural competence. Hughes

and Hood9 have shown that learning about specic

cultural groups o the local community improves

cultural sensitivity in nursing students.

Fewer than one-quarter o the students in our

study could identiy a specic cultural group that

they knew well. Furthermore, their acknowledgment

o barely knowing other cultures speaks to the acute

need or a multicultural curriculum. The students

surveyed were early in their sophomore year and

were just beginning their multicultural curriculum,

which is designed to improve both knowledge and

perceived importance about culture. The outcomes

o this curriculum are being investigated, but are as

yet unknown.

Despite the admission o inadequate knowl-

edge, this group o students believes that cultural

sensitivity in dental practice is important. Those

who knew at least one cultural group well perceived

cultural sensitivity as more important than those whodid not know another culture well. Perhaps those

students who have a relationship with someone rom

another culture can better appreciate the diculties

o cross-cultural health care and the benets o health

care providers cultural sensitivity. This suggests that

students may benet rom learning about the charac-

teristics o other cultures and rom interacting with

people rom other cultures. Benets might include

knowledge as well as an openness to appreciating

and using culturally sensitive dental care practices.

Ironically, the practice perceived as least important

to these students was participation in cultural compe-tence proessional activities. Students who do not see

the importance o these activities may be particularly

dicult to engage in a multicultural curriculum. This

underscores the importance o maintaining a diverse

student body and aculty.10 A diverse dental school

can promote both ormal learning through curriculum

and inormal learning through personal relationships

with aculty and students.

Students and aculty alike oten express the

concern that it is impossible to know every aspect

o every culture that they may encounter in practice.

There are three important points to make in response

to this concern. First, there are techniques that can be

used in virtually all cross-cultural situations, regard-

less o the patients specic cultural background. For

example, the Culture and Health-Belie Assessment

Tool (CHAT) teaches a core set o questions to elicit

patients culturally specic ideas about health and

disease across cultures.11 At the UConn SDM, we

have incorporated the CHAT model and give students

the opportunity to roleplay using it with standardized

patients.

Second, while it is unrealistic or dentists to

become expert in all cultures, it is quite realistic or

a dentist to learn some basic characteristics o the

cultural groups who will be treated in large numbers

in his or her specic setting. Programs need not be

all-inclusiveor completely group-specic to discuss

variations in the valuesand communication styles

o various racial and ethnic groups. However, the

recommendation has been made that programs aimed

at enhancing the provision o culturally eective

health care should be tailored to the demographics

o the population served.12,13 For example, Hartord

serves a large Puerto Rican community. A dentist

who is practicing in that area would do well to learn

about Puerto Ricansor example, their common

dietary practices, common home remedies, amily

roles and decision-making authority, patterns o

high-risk behaviors such as tobacco, the ormat ornames, and the importance o values such as sympatia

andfamalismo, as well as a ew phrases in Spanish.

At the UConn SDM, in a small group seminar set-

ting, students give presentations on the biological

and nonbiological determinants o health and oral

health or our o the common cultural groups they

are likely to see in practice in Connecticut. These

student presentations are developed with the help

o an appropriate textbook14 and relevant scientic

articles assigned by the aculty.

Third, cultural competence is a continual learn-

ing process. A goal o mastering a particular cultureindicates either a limited willingness to integrate new

inormation or an unrealistic goal. In either case, an

ongoing openness to learning is a more appropriate

and benecial goal. We encourage students and aculty

to take a lielong learning approach to diversity.

There are several dangers that should be noted

when teaching a cross-cultural curriculum. First,

ocusing on a single given cultural group may not

prepare students to interact eectively with a wide

variety o cultural groups. This is why, in addition


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7. Goode T, Brown M. Validation o the cultural competence

health practitioner assessment and implications or use

in cultural competency training. In: Proceedings o the

12th Annual Nursing Research Conerence, Health Care

Disparities: Cultural Perspectives Across the Liespan,

Howard University, Washington, DC, March 22, 2006, p.

40. At: www.cpnahs.howard.edu/nursing/MEC/MEC%20

Program%20Booklet%202006.pd. Accessed: December1, 2007.

8. Lister P. A taxonomy or developing cultural competence.

Nurse Educ Today 1999;19:3138.

9. Hughes KH, Hood LJ. Teaching methods and an outcome

tool or measuring cultural sensitivity in undergraduate

nursing students. J Transcult Nurs 2007;18:5762.

10. Formicola AJ, Klyvert M, McIntosh J, Thompson A, Davis

M, Cangialosi T. Creating an environment or diversity

in dental schools: one schools approach. J Dent Educ

2003;67(5):4919.

11. Rosen J, Spatz E, Gaaserud A, Abramovitch H, Weinreb

B, Wenger NS, Margolis CZ. A new approach to devel-

oping cross-cultural communication skills. Med Teacher

2004;26:12632.

12. American Academy o Pediatrics Committee on Pediatric

Workorce. Culturally eective pediatric care: education

and training issues. Pediatrics 1999;103:16770.

13. Rayman S, Almas K. Transcultural barriers and culturalcompetence in dental hygiene practice. J Contemp Dent

Pract 2007;4:4351.

14. Purnell LD, Paulanka BJ. Transcultural healthcare: a

culturally competent approach. Philadelphia: F.A. Davis

Company, 1998.

15. Yearwood EL, Brown DL, Karlik EC. Cultural diversity:

students perspectives. J Transcult Nurs 2002;13:237

40.

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